# 25 - Opioid withdrawal in a community setting

# Opioid withdrawal in a community setting

516
The Maudsley® Prescribing Guidelines in Psychiatry
CHAPTER 4
Opioid detoxification and reduction regimens
Opioid maintenance can be continued for a few weeks to almost indefinitely, depending 
on clinical need. Some patients are keen to detoxify after short periods of stability and 
other patients may decide to detoxify after longer periods on maintenance prescriptions. 
All detoxification programmes should be part of a care programme. Given the risk of 
serious fatal overdose after detoxification, services providing such treatment should educate the patient about these risks and supply them with naloxone and overdose training 
for emergency use.
In the UK, NICE guidelines state ‘dose reduction can take place over anything from a 
few days to several months, with a higher initial stabilisation dose taking longer to taper’ 
and indicate that ‘up to 3 months is typical for methadone reduction, while buprenorphine 
reductions are typically carried out over 14 days to a few weeks’.86 In practice, a detoxification in the community may extend over a longer period if this facilitates the client’s 
comfort during the process, compliance with the care plan, ­continued abstinence from 
illicit use during detoxification and subsequent abstinence following detoxification.
Detoxification in an in-­patient setting may take place over a shorter time than in 
the community (e.g. 14–21 days for methadone and 7–14 days for buprenorphine) ‘as 
the supportive environment helps a service user to tolerate emerging withdrawal 
symptoms’.87 As in the community, stabilisation on a dose of a substitute opioid is 
first achieved, followed by gradual dose reduction, with additive medications 
­judiciously prescribed for withdrawal symptoms as needed.
Detoxification carries a recognised risk of relapse and fatal overdose. Therefore, if 
a patient is being detoxified there needs to be adequate aftercare in place, such as a 
­rehabilitation programme and community support. For patients having emergency 
psychiatric or medical admissions, detoxification is not usually indicated unless with 
the support of specialist services and where aftercare arrangements are in place.
Opioid withdrawal in a community setting
Methadone withdrawal
Following a period of stabilisation with methadone or a longer period of maintenance, 
the patient and prescriber may agree a reduction programme as part of a care plan to 
reduce the daily methadone dose. The usual reduction would be by 5–10mg weekly or 
every 2 weeks, although there can be variation in the reduction and speed of reduction. In 
the community setting, patient preference is the most important variable in terms of dose 
reduction and rate of reduction. The detoxification programme should be reviewed regularly and remain flexible to adjustments and changes, such as relapse to illicit drug use or 
patient anxieties about speed of reduction. Factors such as an increase in heroin or other 
drug use or worsening of the patient’s physical, psychological or social well-­being may 
warrant a temporary increase or stabilisation of the dose or a slowing down of the reduction rate. Towards the end of the detoxification, the dose reduction may be slower: 1–2mg 
per week. A longer length of stability on maintenance treatment and prolonged reduction 
schedules (up to a year) substantially improve the chances of achieving abstinence.88
Buprenorphine withdrawal
The same principles as for methadone apply when planning a buprenorphine detoxification regimen. Dose reduction should be gradual to minimise withdrawal discomfort 
(Table 4.19).